critical“the provider continued to have no system for checking people's medicines administration records and daily logs for quality and safety issues.”
moderate“the provider's safeguarding policy did not reference the local authority's safeguarding process.”
critical“systems were either not in place or robust enough to demonstrate the quality and safety of services was effectively managed.”
record keeping
2 findings
moderate“Records of people's care reviews remained poor and lacked sufficient detail to provide a clear audit trail of when changes were made to people's care and why.”
critical
“Records relating to staff and people were disorganised and not easily accessible to authorised personnel.”
medication management
2 findings
minor“staff did not always have access to clear information on where to apply people's creams.”
critical“the provider had failed to ensure the proper and safe management of medicines. This placed people at an increased risk of medicine-related harm.”
supervision appraisal
2 findings
minor“the management team carried out spot checks on staff, but this practice was not well-embedded as this process was newly established.”
critical“Staff had not received regular supervisions in line with the provider's policies and procedures... had not received an annual appraisal.”
care planning
1 finding
critical“Care plans were not always in place... Information held in people's homes resembled a 'task list' and provided bullet points with brief details about the care they required.”
staff training
1 finding
critical“Staff had not received appropriate induction and training to prepare them for their role... trainers did not have the skills or qualifications to train staff in these areas.”
safeguarding
1 finding
critical“the provider had failed to operate effective recruitment procedures to ensure all persons employed were suitable for the purposes of carrying on a regulated activity.”
person centred care
1 finding
critical“the provider had failed to ensure all people had received a robust of assessment of their needs and preferences.”
consent capacity
1 finding
moderate“pre-assessment documentation did not address people's mental capacity to consent to their care and support arrangements.”
incident learning
1 finding
moderate“the provider's engagement practices did not robustly promote an improvement culture at the service.”
communication with families
1 finding
moderate“we were not confident the service was consistently identifying people who fell within the scope of AIS”
missed or late visits
1 finding
minor“A relative told us how this negatively impacted a person's evening routine as staff would put them to bed early if they arrived early.”